Claudia Esparza
Northridge,CA
Summary
Skilled claims operations leader with proven track record of driving process improvements and optimizing workflows. Strong focus on team collaboration and delivering results, ensuring adaptability to changing needs. Expertise includes risk management, strategic planning, and regulatory compliance, combined with reliable and results-oriented approach.
Overview
14
14
years of professional experience
Work History
Supervisor of Claims Operations
Centene Corporations
07.2023 - Current
- Assisting New Hires with questions/Mentoring
- Claim Review
- Project Review (ALL States)
- Running Reports for Team
- Conducting 1:1, Coaching’s/Feedback and Yearly Performance Reviews
Sales Associate
Kohls Department Store
12.2022 - 08.2024
- Organized racks and shelves to maintain store visual appeal, engage customers, and promote specific merchandise.
- Handled cash transactions efficiently while adhering to company cash handling policies, ensuring accuracy in all financial exchanges.
- Built relationships with customers to encourage repeat business.
- Managed returns, exchanges and refunds in accordance with store policy.
- Maintained calm demeanor and professionally managed issues in busy, high-stress situations.
- Prepared merchandise for sales floor by pricing or tagging.
- Helped customers locate products and checked store system for merchandise at other sites.
- Answered customer questions about sizing, accessories, and merchandise care.
- Boosted customer satisfaction levels through exceptional service, addressing concerns promptly, and providing a welcoming store environment.
- Performed cash, card, and check transactions to complete customer purchases.
Supervisor of Appeals and Grievance Department Commercial Team
Health Net
12.2019 - 07.2023
- Oversaw daily operations of the department, ensuring smooth workflow and timely completion of tasks.
- Applied strong leadership talents and problem-solving skills to maintain team efficiency and organize workflows.
- Improved customer satisfaction with timely response to inquiries, addressing concerns, and finding effective solutions.
- Increased team productivity by implementing efficient workflows and setting clear expectations for staff members.
- Resolved conflicts among team members promptly, maintaining a harmonious working environment conducive to productivity.
- Enhanced communication within the team by holding regular meetings and encouraging open dialogue among all members.
- Mentored junior staff members in their career development, sharing knowledge from years of experience in the field.
- Conducted performance evaluations for staff members, identifying areas of improvement and guiding professional development plans.
Lead of Appeals and Grievance Department HMO Team
Health Net
02.2019 - 12.2019
- Managed time efficiently in order to complete all tasks within deadlines.
- Organized and detail-oriented with a strong work ethic.
- Used critical thinking to break down problems, evaluate solutions and make decisions.
- Developed and maintained courteous and effective working relationships.
- Skilled at working independently and collaboratively in a team environment.
- Excellent communication skills, both verbal and written.
- Demonstrated respect, friendliness and willingness to help wherever needed.
- Assisted with day-to-day operations, working efficiently and productively with all team members.
- Paid attention to detail while completing assignments.
- Strengthened communication skills through regular interactions with others.
Senior Appeals and Grievance Coordinator
Health Net
03.2017 - 02.2019
- Conducted regular audits of resolved cases to identify potential improvements or errors within the system.
- Collaborated closely with stakeholders to ensure fair resolutions were achieved in each case while upholding company policies and regulations.
- Developed tailored strategies for unique grievance situations that led to customer satisfaction while maintaining compliance with company policies.
- Identified areas for policy improvement through thorough analysis of recurring grievance themes, leading to proactive problem resolution.
- Improved interdepartmental communication, ensuring timely updates on case progress and resolutions.
- Managed high caseloads diligently by effective organization strategies that maintained accuracy and timeliness during peak periods.
- Established positive relationships with internal departments, enhancing cooperation when resolving cross-functional grievances.
- Streamlined the complaint intake process for faster response times and improved customer satisfaction.
- Conducted comprehensive investigations on complex cases, leading to successful outcomes and satisfied clients.
Medicare Solutions - Project Coordinator
Health Net
09.2016 - 03.2017
- Assisting Project Managers and Director in scheduling meetings
- Reporting SNP Delegation Report
- Excel and Access System
- Reporting
Senior Appeals and Grievance Coordinator
Health Net
10.2014 - 09.2016
- CTS oversight (Arizona, Oregon, and Washington States)
- Auditing
- Case and Letter Review
- Communicating with our Contracted Provider
- Review and handle expedited cases
- Reporting
Appeals and Grievance Coordinator for CA State
Health Net
12.2010 - 10.2014
- Assisting Member’s with Denials, Complains and Post Service Appeals
- Assisting our Nurses and Medical Director’
- Working with our Member’s to resolve their issues
- Communicating with our Contracted Provider
- Review possible expedited cases
- Triaged cases to coordinators/Screen for possible Expedited Review
Education
High School Diploma - General Studies
06.2002
Skills
- Proven patience
- Self-discipline
- Personal integrity
- Professional integrity
- Team building
- In-depth claims knowledge
- Knowledge of all commercial lines of business
- Strong work ethics
- Team player
- Positive attitude
- Deadline-driven
- Good written communication
- Exercises good judgment
- Data-driven decision making
- Continuous improvement mindset
- Quality assurance standards
- Vendor relationship management
- Project management experience
- Claims analysis
- Claims processing
- Teamwork and collaboration
- Customer service
- Problem-solving
Languages
Spanish
Full Professional
English
Full Professional
Timeline
Supervisor of Claims Operations
Centene Corporations
07.2023 - Current
Sales Associate
Kohls Department Store
12.2022 - 08.2024
Supervisor of Appeals and Grievance Department Commercial Team
Health Net
12.2019 - 07.2023
Lead of Appeals and Grievance Department HMO Team
Health Net
02.2019 - 12.2019
Senior Appeals and Grievance Coordinator
Health Net
03.2017 - 02.2019
Medicare Solutions - Project Coordinator
Health Net
09.2016 - 03.2017
Senior Appeals and Grievance Coordinator
Health Net
10.2014 - 09.2016
Appeals and Grievance Coordinator for CA State
Health Net
12.2010 - 10.2014